128) ANSWER

d.	TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap).

RATIONALE

For an adult with no previous tetanus immunizations, TIG and Tdap are recommended. The other immunizations are not sufficient for this patient.

127) Answers

A. Lower back or flank pain that worsens with activity
B. Hematuria

Rationale

•Common clinical manifestations of PKD include flank or lower back pain, frequent UTIs, hematuria, proteinuria, calculi, and hypertension.

•PKD does not cause an adrenal crisis.

•Nausea is not commonly associated with PKD.

126) Answer

B. A systolic murmur heard over the left sternal border

Rationale

•A typical systolic ejection murmur heard loudest at the upper left strenal border is indicative of pulmonic stenosis. A thrill may be present in the upper left sternal area or at the suprasternal notch.

•Pulmonary stenosis is the narrowing of the pulmonary valve or the pulmonary artery just distal to the valve. Inability of the right ventricle to evacuate blood may lead to right ventricular hypertrophy.

•Most patients with pulmonary stenosis are asymptomatic. Severe stenosis can cause exertional angina, syncope, or sudden death.

•Exertional dyspnea is more often associated with severe aortic stenosis or tetralogy of Fallot.

•Thrills are felt, not heard.

•Cyanosis does not usually occur with only pulmonic stenosis.

125) ANSWER

C)Liver

RATIONALE

Amebic infection can be carried via the blood to other organs, with the liver as the most common site, causing liver abscess. Recall that the liver is structurally close to the GI tract.

124) ANSWER

C) Hydroxyzine (Atarax)

RATIONALE

Hydroxyzine hydrochloride is an antihistamine that is a competitive inhibitor of the H₁ receptor. It is used to treat various reactions that are mediated by histamine. It will decrease the pruritus produced by the release of histamine. Cimetidine is an H₂ histamine antagonist and these agents are not effective against hypersensitivity reactions. Lorazepam is a short-acting benzodiazepine that is indicated for anxiety. Bupivacaine is a local anesthetic for nerve blocks. The core issue of the question is knowledge of which drug relieves itching. Use specific drug knowledge and the process of elimination to make a selection.

123) ANSWER

B) Excessive rubbing of the eyes

RATIONALE

Symptoms of decreased visual acuity are squinting to focus, excessive tearing of the eyes, and rubbing of the eye. Language would not be affected by diminished vision. To distinguish among the other options, recall signs of visual impairment at various ages.

122) ANSWER

B) Father of client who has had urinary stones twice.

RATIONALE

The greatest risk factor for stone formation is a prior personal or family history of urinary calculi. The other answers are important information to know but do not contribute greatly as risk factors. Recall that there is thought to be a genetic link to incidence of renal stones.

121) ANSWER

D) Neuromuscular clinical manifestations.

RATIONALE

Although all systems are impacted by calcium imbalance, the major clinical manifestations of calcium imbalance are due to either increased or decreased neuromuscular irritability. Note that the question does not specify if calcium is decreased or elevated. Recall the major system affected by calcium to choose option 4.

120) ANSWER

 B)  "I can take 2-3 tablets at once if I have severe pain."

RATIONALE

Clients must understand that just one sublingual tablet should be taken at a time. After rest and a five minute interval, a second and then a third tablet may be necessary. 

119) ANSWER

 B)  Two years of age

RATIONALE

A child should be at least 2 years of age to use the radial pulse to assess heart rate. 

118) ANSWER

 B)  Sliced bananas

RATIONALE

Finger foods should be bite-size pieces of soft food such as bananas.

117) ANSWER

 A)  Restrict visitors to immediate family

RATIONALE

Maintaining a quiet environment will assist in decreasing cerebral swelling and rebleeding.

116) ANSWER

2. Monitoring the client’s vital signs.

3. Notifying the physician of the client’s symptoms.

RATIONALE

The symptoms of nausea and dizziness

in a client with peptic ulcer disease may be indicative

of hemorrhage and should not be ignored. The

appropriate nursing actions at this time are for the

nurse to monitor the client’s vital signs and notify

the physician of the client’s symptoms. To administer

an antacid hourly or to wait 1 hour to reassess

the client would be inappropriate; prompt intervention

is essential in a client who is potentially experiencing

a gastrointestinal hemorrhage. The nurse

would notify the physician of assessment fi ndings

and then initiate oxygen therapy if ordered by the

physician.

115) Answer

C. Pelvimetry

Rationale

•Pelvimetry is not routinely included in the prenatal assessment, unless the patient is at high risk.

•Pelvimetry assesses the female pelvis to help in determining the need for a C-section.

•HIV testing is now considered routine.

•History and a CBC are important data used to help plan the pregnancy and birth.

114) ANSWER

2. Two to three soft stools per day.

RATIONALE

The expected effect of lactulose is for the

client to have two to three soft stools a day to help

reduce the pH and serum ammonia levels, which

will prevent hepatic encephalopathy.

113) ANSWER

3. An 80-year-old client who has poor oral

hygiene and is dehydrated.

RATIONALE

Parotitis is infl ammation of the parotid

gland. Although any of the clients listed could

develop parotitis, given the data provided, the one

most likely to develop parotitis is the elderly client

who is dehydrated with poor oral hygiene. Any client

who experiences poor oral hygiene is at risk for

developing parotitis. To help prevent parotitis, it is

essential for the nurse to ensure the client receives

oral hygiene at regular intervals and has an adequate

fl uid intake.

112) ANSWER

1. Anxiety

RATIONALE

1 Because the compulsive ritual is used to control anxiety, any attempt to prevent the

action will increase anxiety.

2 Underlying hostility is considered to be part of the disorder itself, not a reaction to an

interruption of the ritual. 3 This is possible only if the anxiety reached panic levels and

caused the person to express anger overtly. 4 This is not a pattern of behavior

associated with this disorder.

111) ANSWER

4. Strategies to handle stress

RATIONALE

Although older adults may be faced with multiple stressors as they age, how

people cope with stress remains fairly constant throughout life.

1 Decreases in the senses of taste and smell are noted as people age. 2 GI motility

decreases slightly with aging; sedentary lifestyles and lack of dietary fiber compound

the problem. 3 Muscle strength decreases with aging.

110) ANSWER

4. Medication.

RATIONALE

Medication noncompliance is a primary

cause of exacerbation in chronic mental illnesses. Of

the issues listed, medications should be addressed

fi rst. Other issues, such as family, marriage, and

fi nances can be addressed as client stabilization is

maintained.

109) ANSWER

3. Hyperkalemia.

RATIONALE

Lisinopril is an angiotensin-converting

enzyme (ACE) inhibitor. Hyperkalemia can be a side

effect of ACE inhibitors. Because of this side effect,

ACE inhibitors should not be administered with

potassium-sparing diuretics.

108) ANSWER

4. Eating a soft, bland diet.

RATIONALE

Clients with stomatitis (infl ammation

of the mouth) have signifi cant discomfort, which

impacts their ability to eat and drink. They will

be most comfortable eating soft, bland foods, and

avoiding temperature extremes in their food and liquids.

Gargling with an antiseptic mouthwash will be

irritating to the mucosa. Mouth care should include

gentle brushing with a soft toothbrush and fl ossing.

107) ANSWER

2. The medication may cause some transient eye

discomfort

RATIONALE

Timolol can cause some eye discomfort

when administered. It is important for the client

to continue to take the drug. Glaucoma eyedrops

should be administered as prescribed, not whenever

the client desires. The client with glaucoma needs to

take eye medication on an ongoing basis to control

the disorder and prevent vision damage. There is no

need to refrigerate the drug.

106) ANSWER

1. Paradoxical excitement.

RATIONALE

Although all of the side effects listed are

possible with Ativan, paradoxical excitement is

cause for immediate discontinuation of the medication.

(Paradoxical excitement is the opposite reaction

to Ativan than is expected.) The other side

effects tend to be minor and usually are transient.

105) ANSWER

2. Wear a gown, mask, and gloves before entering

the room.

4. Place the child in a negative air-flow room.

RATIONALE

Gowns, mask, and gloves are needed

before the nurse or anyone can enter the room of

a client who has chickenpox because the varicella

virus is spread by air, droplets, and contact. It

is very contagious so a negative-air fl ow room is

recommended. Contact isolation only includes a

gown and gloves. Because varicella is spread by air

and contact, a private room is needed. The child

should remain in isolation until all lesions have

crusted.

104) ANSWER

3. Relaxed and sleeping quietly

RATIONALE

It is expected that a newborn will enter a sleep phase about 30 minutes after birth.

1 After the initial cry, the baby will settle down and become quiet and alert. 2 This occurs

after the first sleep. 4 This occurs during the first period of reactivity.

103) ANSWER

3. Esophagitis.

RATIONALE

3Cimetidine (Tagamet) is a histamine

receptor antagonist that decreases the quantity of

gastric secretions. It may be used in hiatal hernia

therapy to prevent or treat the esophagitis and

heartburn associated with refl ux. Cimetidine is

not used to prevent refl ux, dysphagia, or ulcer

development.

102) ANSWER

2. Reversible separation

RATIONALE

2 Preschoolers view death as a separation; they believe the deceased will return to

life. This is part of their fantasy world.

1 Preschoolers view death as a separation, or possibly a kind of sleep, and expect the

deceased to return or wake up. 3 The preschooler does not yet have the understanding

that older people are more likely to die. 4 The preschooler believes that the separation

was initiated by the deceased, not by another force.

101) ANSWER

A. Ego interity despair

RATIONALE

The sense of ego interity comes from satisfaction with life and acceptance of what has been and what is .Despair is due to guilt or remorse over what might have been .

100) Answer

C. Fetal alcohol syndrome (FAS)

Rationale

•Physical features of FAS include deformities such as a small head and brain, sunken nasal bridge, thin upper lip, small teeth, and an upturned nose.

•FAS can also cause vision difficulties, mental retardation, short attention span, delayed mental development, and poor impulse control.

•Down’s syndrome symptoms include short stature, short wide neck, slanted eyes, low set ears, hypotonia, mental retardation, and learning disabilities.

•Klinefelter’s syndrome presents in males as less facial and body hair, reduced muslce mass and strength, broad hips, gynecomastia, and hypogonadism.

•Signs and symptoms of mercury poisoning are manifold and systemic, including peripheral neuropathy, skin discoloration (pink), swelling, shedding of the skin, tremors, visual and hearing impairment, and fatigue.

99) ANSWER

A)  Assists the client to clarify the meaning of what the client is communicating

RATIONALE

Clarification is a facilitating/therapeutic communication strategy. Approval, changing the focus/subject, and advising are non-therapeutic/barriers to communication. 

98) ANSWER

D)	No bowel movement for 3 days

RATIONALE

With opioid analgesics, observe for respiratory depression, sedation, and constipation. Bruising is not related to the analgesic, but could be the result of corticosteroids or previously used anticoagulants. Elevated heart rate could be the result of bronchodilators. Some antibiotics can lower platelet count.

97) ANSWER

B) Congestive heart failure (CHF)

RATIONALE

Oprelvekin (Neumega) can cause cardiopulmonary insufficiency with irregular heart rate and fluid retention. Thus, it is a nursing priority to assess the client frequently for signs and symptoms of congestive heart failure. The other options do not address this priority concern. The core issue of the question is knowledge of adverse drug effects of oprelvekin. Use specific nursing knowledge and the process of elimination to make a selection.

96)Answer

D. Rectosigmoid colon

Rationale

•Adenocarcinomas of the large intestine make up around 98% of all neoplasms of the colon. 75% of which occur in the rectum or sigmoid colon.

•Neoplasms of the colon are linked with diets low in fiber, high in fat, and high in meats. They are also associated with abnormalities of the villi caused by Crohn’s disease, Gardiner’s syndrome or familial polyposis.

95)Answer

D. Oblique fracture

Rationale

•An oblique fracture is when the fracture is diagonal to the bone’s long axis.

•A comminuted fracture is when the bone is splintered or crushed, and has multiple fragments.

•A transverse fracture is when the bone is fractured at a right angle to the long axis.

•A linear fracture is when the bone is fractured parallel to the long axis.

94)Answer

A. While assessing the surgical dressing, check the right posterior axilla

Rationale

•After a mastectomy, if there is drainage or bleeding from the surgical site, it can seep down due to gravity and may soak the posterior axillary portion of the dressing. The nurse must therefore check the right posterior axilla to detect early bleeding.

•For early-stage breast cancer that has spread to the lymph nodes, modified radical mastectomy can be helpful. Raising the arms above the head is discouraged during the early post operative recovery stage because it can put strain on the incision and cause pain.

•Position the patient in semi-fowler’s position with the arm elevated on pillows to decrease edema. Position the patient on her back or unaffected side, never on the on affected side as this could increase edema and cause pain.

•Blood pressure, venipunctures, and IV sites must not involve the use of the affected arm.

93)Answer

B. Pain around the infusion site

Rationale

•A vesicant is an agent that causes tissue irritation and possible tissue necrosis. Signs of extravasation (Pain around infusion site) should be taken seriously because of the risk of tissue necrosis.

•Rash, nausea, dizziness, and dry mouth are all common side effects of chemotherapy and are not life-threatening.

92)Answer

C. “I cannot give out information regarding any patient”

Rationale

•A nurse cannot release any information to unauthorized people.

•The request does not need to be submitted in writing, the patient needs to authorize the release of information or tell the employer himself.

91) ANSWER

A) Hemorrhoids

RATIONALE

Obstruction to portal blood flow causes a rise in portal venous pressure resulting in splenomegaly, ascites, and dilation of collateral venous channels predominantly, in the paraumbilical and hemorrhoidal veins, the cardia of the stomach, and extending into the esophagus. Look for the option that would reflect increased venous pressure.

90) ANSWER

C) Rupture of the uterus.

RATIONALE

Although rupture of the uterus is rare, there is an increased risk for multiparas and clients undergoing induction or augmentation of labor. Early signs include pain and a tearing sensation, signs of shock, and fetal distress. Blood loss is usually severe, but might not be visible. Amniotic fluid embolus is frequently associated with cardiac and respiratory distress. Symptoms of precipitate labor and uterine prolapse do not include pallor, diaphoresis, or fetal distress. Critical words in this question are tearing sensation and oxytocin. A tearing sensation is the classic symptom of uterine rupture, a risk with oxytocin administration. Eliminate options 1, 2, and 4, as the symptom presented in the question would not be present with these conditions.

89) ANSWER

A) Infection.

RATIONALE

Prednisone is a synthetic corticosteroid that depresses the immune response and increases susceptibility to infection. Steroids mask infection; therefore, the child must be assessed for subtle signs and symptoms of illness. The core concept is side effects of the drug.

88) ANSWER

B) Use good oral hygiene.

RATIONALE

The provision of good oral hygiene will reduce the chance of stomatitis, which is common in immunosuppressed clients with cancer, who are in need of this medication. There is no need to receive vitamin B₆ concurrently (option 1). Alopecia and elevated blood glucose levels (options 3 and 4) are not related to sargramostim. Note that the client has cancer, and is receiving chemotherapy. Since these clients are high-risk for stomatitis, try to prevent this complication of chemotherapy. This should lead to the option 2, which addresses prevention of stomatitis.

87) ANSWER

D) An adult with varicella zoster

RATIONALE

Although hepatitis is associated with cholestasis (option 2), the most likely candidate would be someone with a viral infection. A classic example is someone with varicella zoster. Options 1 and 3 are not related to hepatitis. Other causes include alcohol, toxins, and severe hepatocellular damage. Select the option that describes a viral infection.

86) ANSWER

D) Coffee

RATIONALE

Caffeine in coffee or tea can have an additive effect with theophylline, and therefore coffee should be eliminated from the meal tray. Peas (option 1), beans (option 2), and milk (option 3) are not problematic because they do not contain caffeine. Recall knowledge of the side effect of theophylline, vasodilation, to be led to the correct answer. By eliminating caffeine from the client s food tray, the additional additive effect of caffeine can be avoided.

85) ANSWER

C) Enuresis

RATIONALE

Childhood disorders that appear to be genetically transmitted include enuresis, autism, mental retardation, some language disorders, Tourette's syndrome, and attention-deficit hyperactivity disorder (ADHD). Of these, autism is the more pervasive disorder. Anxiety (option 1), sleepwalking (option 2), and oppositional defiance disorder (option 4) do not appear to be genetically transmitted. Notice that autism is a more pervasive problem than the other three options. Recall statistics about childhood mental health disorders to make a selection.

84) ANSWER

1. Left occipital anterior (LOA).

RATIONALE

1. The nurse’s findings upon performing

Leopold’s maneuvers indicate that the

fetus is in the left occiput anterior position

(LOA)—that is, the fetal back is felt

on the mother’s left side, the small parts

are felt on her right side, the buttocks

are felt in the fundal region, and the

head is felt above her symphysis.

2. The findings after the nurse performs

Leopold’s maneuvers do not indicate that

the fetus is in the left sacral posterior (LSP)

position; in that position, the fetus’s buttocks

(S or sacrum) are facing toward the mother’s

left posterior (LP), a hard round mass is felt

in the fundal region, and a soft round mass is

felt above the symphysis.

3. The findings after the nurse performs

Leopold’s maneuvers do not indicate that

the fetus is in the right mentum anterior

(RMA) position; in that position, the fetus’s

face (M or mentum) is facing toward themother’s right anterior (RA) and small

objects are felt on the right of the mother’s

abdomen with a flat area felt on the mother’s

left side.

4. The findings after the nurse performs

Leopold’s maneuvers do not indicate that

the fetus is in the right sacral posterior

(RSP) position; in that position, the fetus’s

sacrum (S) is facing the mother’s right posterior

(RP) and a hard round mass is felt in

the fundal region while a soft round mass is

felt above the symphysis.

83) ANSWER

 C)  Urinary output

RATIONALE

Calcium EDTA is toxic to the kidneys. Urine output must be measured to monitor renal function. 

82) ANSWER

B)  Eyes

RATIONALE

Keratitis is a corneal ulcer or abrasion. Keratitis is caused by exposure and requires application of moisturizing ointment to the exposed cornea and a plastic bubble shield or eye patch. 

81) ANSWER

C)  Decreased potassium

RATIONALE

In bulimia, loss of electrolytes can occur in addition to signs and symptoms of starvation and dehydration. 

80) ANSWER

A)  Hourly urine output

RATIONALE

Clients who have had an episode of decreased glomerular perfusion are at risk for pre-renal failure. This is caused by any abnormal decline in kidney perfusion that reduces glomerular perfusion. Pre-renal failure occurs when the effective arterial blood volume falls. Examples of this phenomena include a drop in circulating blood volume as in a cardiac arrest state or in low cardiac perfusion states such as congestive heart failure associated with a cardiomyopathy. Close observation of hourly urinary output is necessary for early detection of this condition.